Provider Demographics
NPI:1598247546
Name:LIST, ELENA (LICSW)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:LIST
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 RAYMOND WAY
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01721-2431
Mailing Address - Country:US
Mailing Address - Phone:508-340-8995
Mailing Address - Fax:
Practice Address - Street 1:67 RAYMOND WAY
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:MA
Practice Address - Zip Code:01721-2431
Practice Address - Country:US
Practice Address - Phone:508-340-8995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA104845-SW-LICSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical